Dr. Adeola Olaitan - Interview 40

Brief Outline: Dr. Adeola Olaitan is a consultant gynaecological oncologist at University College London Hospital. She specialises in the treatment of women with gynaecological cancer and has a particular interest in quality of life in young women after treatment for cancer. She is a fully trained general gynaecologist and also treats women with non-cancer related gynaecological problems.

Background: Dr. Adeola Olaitan is a consultant gynaecological oncologist at University College London Hospital.

A doctor explains why women might be referred for colposcopy and what it involves.

Women will normally be referred to colposcopy if their smear is abnormal. There are a number of grades of smear abnormality. And that varies from mild abnormality, which equates to CIN1, to the severe abnormality, which equates to CIN3.

A smear is a screening test so it doesn’t say that there is a problem with your cervix. An abnormal smear means that there is likelihood that you have a problem with your cervix. So the point in colposcopy is so that the doctor can have a look at the cervix and determine if indeed there is an abnormality. So women are sent to colposcopy so that the doctor can have a look at their cervix to determine if indeed there is an abnormality and if it is an abnormality that needs to be treated.

So what would normally happen is that the woman would meet the doctor and the doctor would explain what the smear test was all about. Colposcopy is having a look with a camera and a low degree of magnification at the cervix. It’s a bit like having a smear test done really, but it takes a little bit longer. The doctor will have a careful look at the cervix and put some solutions on the cervix, which show up any abnormal cells. And they might take some biopsies, which are small tissue samples.

And once that assessment is made the doctor will be able to tell the woman whether or not she requires treatment or whether this is an abnormality that can be watched, or whether indeed there is no abnormality at all on the cervix.

A doctor explains why some women are treated at the colposcopy appointment while others might be...

Some women were treated at the same appointment as their colposcopy appointment. Others had to come back later for treatment. Is there any particular reason for that?

It’s such a variation. It depends on the severity of the abnormality, depends on the woman’s wishes. And it depends on the judgement that the doctor makes at the time. The general rules are, if there is an abnormality that’s obvious, the full limit can be seen, and the women’s willing to be treated at the time, she can be offered treatment on the day.

A doctor explains that, these days, general anaesthesia is completely safe.

General anaesthesia is completely safe now. And I mean these are fit young women who have no other health problems generally speaking. And there is really very little to worry about. The important thing, of course, is to tell the anaesthetist about their fears and they’ll be able to calm them down.

A doctor explains what HPV is and that CIN might be prevented by not smoking.

The high risk Human Papilloma Virus is a sexually transmitted disease. It’s terribly, terribly common, and almost anybody who has had sex has been exposed to it. So it doesn’t, it’s not a mark of promiscuity. It doesn’t mean that you were unhygienic or anything like that. So I suppose, by extrapolation, because we know that HPV causes CIN, you could say that CIN is sexually transmitted.

We know that CIN is caused by the wart virus, the Human Papilloma Virus. The high risk Human Papilloma Virus. Now this is not the same virus that causes genital warts. It’s a slightly different virus; it’s of the same family. It doesn’t cause any visible abnormalities. The thing with high risk Human Papilloma Virus is a lot of people are exposed to it. But most people manage to clear it with their immune system.

The things that increase the risk of CIN or cervical cancer is smoking, because that affects the immune system in the cervix and leads the Human Papilloma Virus to persist and cause the abnormal cell changes which can then develop into CIN3 or cervical cancer. So if people want to know what they can do to protect themselves, I think stopping smoking is the single most important thing.

Does diet or anything else come into it? Women often ask can I make changes to my diet or anything else?

I think there’s no direct evidence, but certainly a healthy diet just helps to keep you well, helps to keep your immune system in good check and therefore it’s just generally good advice. You know, alcohol in moderation, no smoking, and a good healthy diet. And going for your screening when you’re called.

A doctor explains that most cervical screening test (smear) results are normal. Apart from pre...

Over 90% of smears are normal. So the most likely thing to happen is that your smear is reported as normal. Sometimes it can pick up inflammatory change, and sometimes it can pick up infection, like thrush. It’s not designed to pick up sexually transmitted diseases. So a normal smear doesn’t mean you don’t have sexually transmitted disease. And if you’re worried, then you should go to your local sexually transmitted diseases clinic and have a check for that specifically.

The cervical screening age in England was changed from 20 to 25. A doctor explains why cervical...

It [cervical screening] used to start from the age of 20 but what’s become apparent is that women aged between 20 and 25 are most unlikely to have cervical cancer. There are a lot of changes occurring in the lining of the cervix at the time, which can be misinterpreted as cancer.

For example, if you did cervical smears in women aged 20 to 25, one in three of them would have apparent abnormalities, compared with the normal population where 1 in 14 have apparent abnormalities. So there are a lot of what we call false positives. And this may lead women to be treated unnecessarily and then put them at risk of miscarriage and premature labour later in life. So we know from scientific data that it’s safer to wait until 25.

Having said that, if a woman is worried, if she gets symptoms like bleeding after sex or bleeding in between periods, then she must see her GP.

A doctor explains that follow-up care is individualised and depends on a number of factors,...

Follow up is individualised. It depends on what the severity of the abnormality was, what the treatment was, how successful the treatment was. As a general rule, if you’ve had a loop excision for CIN3 and the CIN3 has been removed completely, you’re usually seen back in Colposcopy for one more time. And if the smear is normal at this stage, you’re told to go back to the GP for annual smears for the next 10 years.



*If you have had treatment for cervical abnormalities, you will be screened again six months afterwards. If that screening result shows you have HPV, or you have moderate or worse dyskaryosis, you will be invited back for colposcopy again to see if more treatment is needed. If no HPV is found, you can go back to regular screening every 3-5 years depending on your age (NHS Screening Committee 2014).
 

A doctor explains what cervical erosion is.

I don’t like the term erosion because it implies that there is an abnormality. I prefer the term ectropium. Ectopic tissue is tissue that appears somewhere outside the site of its normal origin. And what an ectropium is, it’s the presence of these glandular cells that I mentioned earlier, on the outside of the cervix. It’s part of normal growth.

When you reach puberty the cervix grows and it grows slightly unevenly so that the inside grows more than the outside. And the effect is that it opens up like a flower so that these cells are visible on the outside. The other condition where it’s more apparent is during pregnancy or women on the combined oral conceptive pill because of the effect of hormones.

It’s completely harmless. It’s a part of normal growth and it’s absolutely nothing to worry about.

A doctor explains that waiting up to eight weeks for colposcopy does no harm.

The statistics from the screening programme for 2008 shows that about 96% of women referred for colposcopy are seen within 8 weeks. And 8 weeks is absolutely fine. Obviously it’s anxiety provoking to have to wait, but the changes aren’t going to progress from pre-cancer to cancer in that length of time.

So it’s okay to wait?

It’s absolutely fine to wait.




*The statistics from the screening programme for 2012-13 shows that about 98.3% of women referred for colposcopy are seen within 8 weeks.
 

A doctor explains that, although there is a small risk of miscarriage and premature labour after treatment for CIN / CGIN, most women go on to have successful pregnancies.

A loop excision for CIN doesn’t affect the ability to get pregnant. It can slightly increase the risk of miscarriage, and it can slightly increase the risk of premature labour.

A cone biopsy also does this but more. It’s more likely to than a loop excision. I think the important thing to recognise is that it is, I think the important thing for women to recognise is that these abnormalities need to be treated. The vast majority of women go on to have successful pregnancies after this treatment. And I think it’s just important to let your obstetrician know when you are pregnant that you’ve been treated, so they can monitor the cervix and intervene if necessary.

A doctor explains that women can try for a baby after the treatment has been completely...

Normally after the treatment you get a bit of bleeding, which can last for three weeks to a month. We normally say no tampons and no sex until the bleeding has completely settled down. And then after that, as long as the treatment has been successful, there’s no reason not to start trying for a pregnancy immediately.

A doctor explains that women might have to wait up to eight weeks for colposcopy or treatment but this does not cause any harm.

The statistics from the screening programme for 2008 shows that about 96% of women referred for colposcopy are seen within 8 weeks. And 8 weeks is absolutely fine. Obviously it’s anxiety provoking to have to wait, but the changes aren’t going to progress from pre-cancer to cancer in that length of time.

So it’s okay to wait?

It’s absolutely fine to wait.



*The statistics from the screening programme for 2012-13 shows that about 98.3% of women referred for colposcopy are seen within 8 weeks.

A doctor explains what CIN is.

People ask ‘what does CIN mean’? What do the words mean? CIN stands for cervical intra-epithelial neoplasia. Cervical – neck of the womb. Intra-epithelial – within the skin. Neoplasia – new growth. So it’s new growth within the cells of the cervix. Not cancer.

 

The cervix is lined by two different types of cells. The inside of the cervix is lined by what we call glandular cells. The outside of the cervix is lined by squamous cells. CIN is an abnormality of the squamous cells.

A doctor explains what HPV is and that CIN3 might be prevented by not smoking.

CIN3 is an abnormality in the cells that line the cervix. The cervix being the neck of the womb. It isn’t cancer. It is an abnormality which, if undetected and untreated over a number of years, can develop into cervical cancer. So the point of cervical screening is to detect this abnormality so that women can be treated and protected from developing cervical cancer.

So you reassure them [women] that it’s not cancer?
 

Yeah absolutely. I mean the whole point in having cervical screening is to prevent cervical cancer. So these are changes that are not cancerous and they are fully treatable.

Can CIN3 develop into cervical cancer?
 

It can if it’s undetected and untreated. And that’s the whole point. And the other point is of course that CIN3 has no symptoms at all. So if you don’t go for your screening you may not know that you have this problem. But if you have the problem and it’s detected, and it’s treated, then it completely reduces the chances of it proceeding to become a cervical cancer.

A doctor talks about the symptoms of cervical cancer.

The most important symptom is bleeding after sex. Bleeding in between periods as well can be an early warning sign of cervical cancer. Later on you can get backache; you can get pelvic pain, like period pains. But these are signs of later cervical cancer.

A doctor explains what CGIN is.

The cervix is lined by two different types of cells. The inside of the cervix is lined by what we call glandular cells. The outside of the cervix is lined by squamous cells. CIN is an abnormality of the squamous cells.

 

CGIN, which stands for cervical glandular intra-epithelial neoplasia, is an abnormality of the glandular cells. It’s much less common that CIN, but it’s similar. It’s a pre-cancerous abnormality which, again, is fully treatable, if it is detected.

Is it more serious than CIN 3 or…?

 

It isn’t more serious. It’s a less common abnormality and it can sometimes be slightly harder to treat because the cells inside the cervix are continuous with the cells inside the womb. But, as long as it detected, it will be treated. And treatment will reduce the risk of it progressing to cancer quite significantly.

A doctor explains how CGIN is treated.

CIN3 is often treated by a loop excision of the transformation zone, which is an outpatient treatment. CGIN is usually treated with a cone biopsy, which requires a general anaesthetic and a day case hospital admission. The point in using a cone biopsy to treat CGIN rather than a loop is it’s important to shape the area that’s removed from the cervix and get right to the top of where the abnormal cells arise.

A doctor explains what a cervical screening test can show.

Over 90% of smears are normal. So the most likely thing to happen is that your smear is reported as normal. Sometimes it can pick up inflammatory change. And sometimes it can pick up infection, like thrush. It’s not designed to pick up sexually transmitted diseases. So a normal smear doesn’t mean you don’t have a sexually transmitted disease. And if you’re worried, then you should go to your local sexually transmitted diseases clinic and have a check for that specifically.

A doctor explains that the bleeding after treatment is normally like a period or slightly heavier.

The bleeding is normally like a period, maybe slightly heavier than a period. And the natural, what usually tends to happen is the bleeding tails off. If it suddenly starts to become heavier, or becomes a bit smelly, then that might imply that there is an infection, in which case they [women] should see a doctor.

A doctor explains that the chances of recurrence after treatment for CIN3 / CGIN are small.

If CIN3 has been completely treated, in other words the abnormality has been removed in it’s entirety with a zone of normal tissue around it, then the chances of it recurring are very, very small. 95% of women do not need any additional treatment.

Somebody who has had CIN3 is at slightly higher risk of developing cancer than somebody who has not had CIN3, and that’s why we advise that these women should have smears every year for ten years. And if the smears are normal, then they can return to the normal screening interval.

And some women were also worried about their daughters. And whether there was any more increased risk now for their daughters?

Well they can be reassured it’s not familial. It doesn’t run in families at all. So their daughters are not at any higher risk.



*A doctor explains that the chances of recurrence after treatment for CIN / CGIN are small.

A doctor talks about the risks of general anaesthesia.

General anaesthesia is completely safe now. And I mean these are fit young women who have no other health problems generally speaking. And there is really very little to worry about. The important thing, of course, is to tell the anaesthetist about their fears and they’ll be able to calm them down.

A doctor explains how treatment for CIN3 or CGIN affects pregnancy and fertility.

A loop excision for CIN doesn’t affect the ability to get pregnant. It can slightly increase the risk of miscarriage, and it can slightly increase the risk of premature labour.

A cone biopsy also does this but more, it’s more likely to than, than a loop excision. I think the important thing for women to recognise is that these abnormalities need to be treated. The vast majority of women go on to have successful pregnancies after this treatment. And I think it’s just important to let your obstetrician know when you are pregnant that you’ve been treated, so they can monitor the cervix and intervene if necessary.

A doctor talks about recurrence and the risks of getting cervical cancer.

If CIN3 has been completely treated, in other words the abnormality has been removed in it’s entirety with a zone of long tissue around it, then the chances of it recurring are very, very small. 95% of women do not need any additional treatment.

Somebody who has had CIN3 is at slightly higher risk of developing [cervical] cancer than somebody who has not had CIN3. And that’s why we advise that these women should have smears every year for ten years. And if the smears are normal, then they can return to the normal screening interval.

And some women were also worried about their daughters. And whether there was any more increased risk now for their daughters?

Well they can be reassured it’s not familial. It doesn’t run in families at all. So their daughters are not at any higher risk.

A doctor talks about the causes of CIN3.

We know that CIN is caused by the wart virus, the Human Papilloma Virus. The high risk Human Papilloma Virus. Now, this is not the same virus that causes genital warts. It’s a slightly different virus; it’s of the same family. It doesn’t cause any visible abnormalities. The thing with high risk Human Papilloma Virus is a lot of people are exposed to it. But most people manage to clear it with their immune system.

The things that increase the risk of CIN or cervical cancer is smoking, because that affects the immune system in the cervix and leads the Human Papilloma Virus to persist and cause the abnormal cell changes which can then develop into CIN3 or cervical cancer.

So if people want to know what they can do to protect themselves, I think stopping smoking is the single most important thing.

Does diet or anything else come into it? Women often ask can I make changes to my diet, or anything else?

I think there’s no direct evidence, but certainly a healthy diet just helps to keep you well, helps to keep your immune system in good check and therefore it’s just generally good advice. You know, alcohol in moderation, no smoking and a good healthy diet. And going for your screening when you’re called.

A doctor talks about the HPV vaccine, who is eligible for it, and its aims.

This is a vaccination that protects young ladies against, there’s two strains, two common strains of the high risk Human Papilloma Virus. The HPV 16 and 18. It’s available on the NHS to girls aged between thirteen and eighteen. And I think it comes as three vaccinations. You get one at time zero, one two months later, and one six months later. And it’s been shown in tests to offer good protection.

Now it’s important to remember that it doesn’t protect against all the Human Papilloma Viruses, so these girls should still go and have screening when they get to the age where they’re eligible for screening. But I think it’s a good idea. And I think it’s ensuring good protection and, over time, should lead to a reduction in the rate of cervical cancer by the order of, people are quoting between 50 and 80%.

A doctor explains that women who have had CIN3 before are only slightly more likely to get it again or cervical cancer. CIN3 is not hereditary, so their daughters aren't at any higher risk.

If CIN3 has been completely treated, in other words the abnormality has been removed in it’s entirety with a zone of long tissue around it, then the chances of it recurring are very, very small. 95% of women do not need any additional treatment. Somebody who has had CIN3 is at slightly higher risk of developing [cervical] cancer than somebody who has not had CIN3, and that’s why we advise that these women should have smears every year for 10 years. And if the smears are normal, then they can return to the normal screening interval.

And some women were also worried about their daughters. And whether there was any more increased risk now for their daughters?

Well they can be reassured it’s not familial. It doesn’t run in families at all. So their daughters are not at any higher risk.